Medicare: Noridian Telephone Reopening Request Guidelines

Beginning September 16, 2013, Part B providers can contact Noridian Telephone Reopening through a single toll free service phone number, 855-609-9960, which includes the Part A and B Provider Contact Centers (PCC), Electronic Data Interchange Support Services (EDISS), Provider Enrollment and User Security.
Telephone Reopenings will be staffed to respond to Part B inquiries Monday – Friday from 6 a.m. – 5 p.m. PT. We will continue to accept telephone reopening requests for items and services Palmetto previously allowed; however, we would also like to inform you of additional telephone reopening services we provide.

Additional Telephone Reopening Services
5 Reopenings per call
Diagnosis additions or changes due to medical necessity (including Local Coverage Determination (LCD) and National Coverage Determination (NCD) denials)
Add modifier AS, 80, 82, 52, 24
Add GV and GW modifier to Hospice claims
Change the MSP type Who Can Request a Telephone Reopening? Physician or supplier Third party authorized by physician or supplier. (Clearinghouse, biller, coder) Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency for Medicare Part B claim determinations Complete Claim(s) Research before Calling Reopenings Claim status inquiries call Interactive Voice Recognition (IVR) at the single toll free customer service number. All other inquiries contact Provider Contact Center (PCC) at the single toll free customer service number. If your facility has received an Electronic Remittance Advice (ERA) or Standard Paper Remittance (SPR) indicating that a claim has denied as unprocessable (e.g. MA130 and CO16), it does not have rights to a reopening or an appeal and must be corrected and submitted as a new claim. NOTE: To ensure that the claim in question is truly finalized, wait 4–5 days following your ERA receipt to call Reopenings. Be Prepared When calling Telephone Reopenings the following information must be available when you call. If the following information is not available, you will be referred back to the IVR to obtain the information prior to completing any telephone reopenings. Please remember there’s a limit 5 reopening requests per call. Caller’s name and phone number Provider name and Medicare billing number, National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) (individual or group) * Beneficiary’s Medicare Health Insurance Claim (HIC) number * Beneficiary’s last name and first initial* Beneficiary’s date of birth * Date of Service (DOS) Internal Claim Number (ICN) of the claim Billed amount Procedure code (CPT or HCPCS) in question Corrective action to be taken on the claim *The elements with an asterisk must be verified for compliance with the Privacy Act. Corrections (changes/additions/deletions) can be made for the following clerical errors or omissions: Diagnosis additions, changes and deletions Place of service changes Clinical Laboratory Improvement Act (CLIA) Numbers changes or additions Mammography Certification Numbers changes or additions Month/Day of service changes Procedure code changes – up and down code Modifiers additions, changes and deletions Add or change post operative dates Assignment changes (Participating to Non-Participating) Changes that may cause an overpayment (ex. down coding) Change the MSP Type – must match the type and primary insurer on file Add 25 modifier to paid Critical Care (99291-99292, 99298) Prolonged Services (99354-99359) All Psychology codes Initial Preventive Physical Examination (IPPE) Codes (G0402-G0405) Change rendering NPI & PTAN of provider – must be within the same group Ground Ambulance miles changes – up to 50 miles Ground Ambulance (A0428) when billed modifiers HH, RH, NH, EH, SH, PH, HI, and IH Ambulance claims denied duplicate when there were two trips at different times Corrections (changes/additions/deletions) cannot be made for the following clerical errors or omissions: Unprocessable claims Claims that require documentation to make a change (too complex) Year of service Claim line additions and deletions MSP Type changes Recoupment issues Claim(s) with initial determination dates over one year old Erythropoietin (EPO) (J0881-J0886, Q4081) Vertebroplasty (22520-22525) Paravertebral Facet Joint (64493-64495, 64635-64636) Claims paid by another contractor (denial message 610) Modifier additions – GA, GY, GX, GZ, QA, QU, QV, Q1, QJ, 21, 22, 23, 66, and 74 must be requested in writing Air Ambulance Transitional codes 99495-99496 Corrections (changes/additions/deletions) may be made for the following clerical errors or omissions, depending on situation. Units /number(s) of service Modifiers Unlisted procedure codes (if code is on adjudication list, we can adjust) Hospice modifiers May add date span and fractions only (77427, 77336, 77417) Note: Lists included above are not all-inclusive. Reopening Filing Limits Requests must be received by Noridian within one (1) year from the original claim processing date determined by the original Medicare Summary Notice (MSN), ERA, or SPR date. Requests received after the one (1) year time limit will be dismissed as untimely. Good cause for late filing will not be considered over the phone and is not applicable for Telephone Reopenings as described in the Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 29, Section 240. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf   Reopening Timeline Calculator available on the Noridian “Appeals” webpage Type remittance advice date in box Click “Check” button Displays date the request must be received at Noridian CMS mandates that Reopening requests be completed by the Medicare Contractor (Noridian) within 60 days from the date the request was received at the Noridian office. Reopening Determination Notification Approved Determination – An ERA or SPR will contain the payment determination. A separate determination letter for fully favorable reopenings is not sent. Per CMS, IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 34, Section 10.2, "If a contractor receives a reopening request and does not believe they can change the determination, they should not process the request." Disclaimer: If any of the above requested changes, upon research, are determined to be too complex, the requestor will be notified that the request needs to be sent in writing, with the appropriate documentation, as a Redetermination. Courtesy of: Noridian https://www.noridianmedicare.com/je/docs/telephone_reopening_request_guidelines.html